Intake Form

Business Information

Company Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address (2nd Address - If Needed)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax: (If Needed)

Toll Free Number: (If Needed)

Website*

Company Email Address*

Business Type / Category*

Products / Services*

Business / Office Hours:

: HH

MM

Payment Methods You Accept [Check all that apply]*

In Business Since:*

Primary Keyword / Tags*

Business Description - Short (200 Characters Max):*

Business Description - Long:

Business Logo: Upload Here

Drop files here or

Photos: Upload Here

Drop files here or

Video URL (Try to give 5 Videos):

Additional Information

Tag Line / Business Slogan:

Specialties (exclusive products, areas of expertise):

Cities Served / Counties Served / Areas Served:

Language Spoken:

Public Wi-Fi

Yes
No

Parking Available:

Yes
No

Reviews:

Testimonials:

Coupons and Special Offers

Brand Names Carried:

Affiliations (BBB Member, Sites, Trade License #, Chamber of Commerce, etc):

Social Media Page URLs (Facebook, Twitter, Pinterest, Instagram, Snapchat, LinkedIn, Google Plus, etc)

Owner Information

Name*

First Last

Position / Job Title*

Owner / Contact Person Gender:*

Male
Female

Owner / Contact Person Date of Birth*

Owner / Contact Person Bio:

Owner / Contact Person Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner / Contact Person Photo:

Drop files here or

Website Login Info: Username / Password / Login URL:*

Google Business Login and URL:*

Domain Email Account: Please set up a email account on your domain for us to use.